School System PT: Question about Eligibility for Therapy

DEAR ERI COMMUNITY: I am a physical therapist (4 years) and on my 2nd in the schools. I am finding that more and more of my referrals are for kids that are falling behind their peers, not for coordination and understanding of tasks rather obesity. My question is ethically… should weight be a deciding factor for eligibility/ dismissal if they demonstrate all areas of coordination, average strength/ROM etc, but when trying to hop or do sit ups/push ups they can go thru the motions, but are unable to clear the floor resulting in low testing scores. Also, what might be the best politically correct way to state weight is a contributing factor to students limitations?

20 Responses to School System PT: Question about Eligibility for Therapy

I use system reviews on my evals. Under cardio pulmonary, I put their weight, height, and bmi. I also put where they fall on the growth charts. I then add a statement. According to the CDC, your child is considered (overweight, obese, healthy or underweight). I do this on every kid. I do not make judgments, just what the charts say. They have a nice calculator on the cdc websites. Also I have include at times. A typical five year according to the CDC weighs between 40 and 60 pounds.

I will put obese children on PT if they can not function in the school environment. We also work with the families. We are fortunate that many of our schools have a clinic staff from the children’s hospital’s. They have an RD that works with the family. We have had some really good success.

I use the word “fitness” to discuss overweight kids. I tell parents its a lack of fitness and they need to move move and give easy ideas like playground play, turn on music and dance , go for walks etc. PT is not extra PE. Many feel like its a one:one gym class.

If they can function in PE, school mobility, and any gross motor activities in the classroom( like music and movement in preK) then they don’t need PT. However, if the weight and lack of fitness is so severe that they can’t function well and, in younger kids, aren’t developing new gross motor skills then they need PT.

Very interesting topic that is sure to come up more frequently. I agree with the above comments that if the lack of “fitness” is truly affecting the child’s ability to efficiently navigate their educational setting and keep pace with their peers than I would make a case for eligibility for PT. Possibly even include the design of a home activities program and consultation with the family as part of the instructional implications. I recently saw a comment in the twitter world referencing Pediatric Physical Therapy that said “all children with a BMI greater than 85 should be referred for a physical therapy evaluation”. Emory University hosted a symposium on this exact topic. Here is the agenda I found with the speakers and topics :http://rehabmed.emory.edu/pt/ce/info/Obesity_MoreInfo_Mission&Agenda.pdf
Carina

Simply being overweight and unable to perform sit ups, etc, does not qualify a child for PT in the schools. However, look at how they function at school.
1. Can they get up and down from the floor? They may demonstrate decreased strength and mobility for floor transfers.
2. Can they walk up and down stairs alternating feet? If not, describe how their poor endurance, decreased strength, etc. impacts this.
3. Can they move quickly in case of an emergency? Describe how their decreased walking or running speed impacts their safety.
4. How is their gait? Do they shuffle their feet a lot which could impact their balance on uneven surfaces?
5. And, it’s ok to add that they are not able to participate with their peers in PE because of decreased endurance. How do exercises impact their heart rate and respiratory rate? Like the PT above that recommended documenting weight, height, and BMI, also document HR and RR before and after exercise.

I have had this discussion many times with my colleagues. I believe that often the obese children have underlying low tone issues. It becomes one of those “chicken or egg scenarios”: did the child become obese because of low tone or is the obesity causing the lack of muscle strength making the child fall behind their peers? Either way, they need more help than the school and the pediatricians can offer, so I will often pick them up for PT if they demonstrate delays. I will record their BMI and write a blurb similar to that stated above about what a healthy weight range would be. Then I write an exercise program that needs to be completed at school and at home. I work out a time that the school one can be completed with the child’s teacher (usually adding in “brain breaks” for the whole class which last a little longer than the typical ones and work on the skills the child I’m seeing needs to work on). I set a time limit that I will be seeing the child at which point they will be decreased to consult to adjust the exercise program. I make the gym teacher aware of everything and bring them in as an ally. In districts where many children are obese, I have helped the gym teacher set up a running program during recess so all children get a little more exercise than they would if they were just playing on the playground.

Childhood obesity is a medical problem and needs to be handled as such. No amount of PT is going to change that unless the family is fully vested in addressing the problem. I agree with the other 2 comments as far as whether an obese child should qualify for treatment, but in my district a child would already need to be classified as well; obesity would not be sufficient to receive PT since it is a MEDICAL condition effecting the child’s performance in school. We recommend kids be seen by a physician for glasses, hearing issues, scoliosis, etc so why not refer for a weight problem?

I think it’s a question of access… Is the student’s obesity impairing the ability to access the educational environment. It has been shown that obese kids perform worse on standardized tests with regard to GM skills (MABC2 or the BOT2, I can’t remember which). If access is an issue, who is the most appropriate discipline to address the need? In my district, APE would address fitness, not PT. If there are additional needs requiring PT, treating the obesity as a secondary factor would definitely be in the plan.
I like the systems review approach mentioned previously with regard to identifying obesity. There is also the question of eligibility… Is the student already eligible for Special Ed or are you considering making them eligible due to obesity (OHI?)? Is obesity a disability? And does it negatively impact the student in the academic setting? Can you treat them under a 504 Plan? (This is variable depending on District/State policy).
I definitely see a need, but I’m not sure that school-based PT, under an IEP, is the appropriate answer given our specific role in special education. I do think we have a lot to offer in this area and I’d love to do after school/education programs outside of the IEP for both the gen Ed and special Ed kids. However, there is always the cost factor (grants maybe??).

I use the NJ core curriculum – grade equivalent for PE goals to assess eligibility. If I find that they lack the timing, rhythm, coordination and timing and especially activities that cross the midline which reuqire timing and rhythm, I pick them up for PT servcies.
Depnding on my assessment, I use the least restrictive service delivery framework to decide the service delivery model. If the child is obese and it is not impacting his school functioning, then maybe he just needs PE modifications and a whole lot of parent informational sessions to increase their awareness about the impact of obesity on cardiovascular fitness/endurance and also on learning and ability to play with peers etc. As many children with attention deficit disorders are also obese, and there is research supporting the impact of physical functioning on academic skills, I always do a sensory motor assessment..basically checking the vestibular and proprioceptive systems and their impact on school functioning.
I know I used to think of PT services only as pull out services, but there are so many different models that are available and as schools PTs we should use all of them.
I am the only PT in my district and have provided services for 10 years- recieved only one referral for obesity primarily and after my assessment found that he has a lot of agility, balance and coordination issues. As physical agility and problem solving during motor activities is proven to improve academic skills like executive functions, I usually coordinate my pull out session to be before his most challenging academic period- in my student’s case..Math.
I think PTs have a great opportunity to expand our services by addressing issues with obesity- we just don’t have to provide traditional pull out sessions, which I have informed my district and parents is just a waste of time, because there is not research that supports weight loss with just 1/week of PT.
I include nutritional training, provide nutrition lessons, I use the gov.plate website to plan my sessions, work with the cafetaria staff etc etc.
I loved Mary’s way of documenting BMI and like her I use the CDC criteria for comments on weight. On another but related subject….did you know that PTs are not included in expert panel on weight loss in NJ and I think that is sad…we are movement specialists afterall.
Just my 2 cents…
I usually offer Bal-a -vis-x ( Balance-Auditory-visual-exercises) and train PE teachers ( the ones who are interested and willing) to embed these activities into their programs.

Bala,
Looking for info as this has been coming up quite a bit for me lately…..
How are you assessing coordination, rhythm, and timing? Are you picking these kids up for direct service, if not what service model are you using? How are you writing goals around these deficits?
Tara

Have you considered doing referrals to local pediatric home care? In addition to PT, OT, and SLPs, many pediatric home care companies have nurses and nutritionists on staff. Therefore in addition to educating parents on gross motor issues and designing a home exercise program they have staff to address health and nutrition.

The question I have to answer is Does the child’s condition affect his/her ability to function safely and adequately in the school environment.
So our assessment includes age specific motor skills from getting off the bus, working in the classroom, school negotiation and various ball/motor skills just to name a few.

Is the child able to keep up with his peers on stairs, walking in the hallway etc…?if a child has a weight problem they may cause him/her to lag behind then we set a gait speed goal on stairs and on level terrain (feet/sec) This will also indicate whether they need special help in the case of an emergency when children have to exit the school in a timely, safe and efficient manner

Mark,
Do you have “norms” for feet/sec for various age/grade ranges? Just curious. I am just wondering how you write your goals for improving pace on stairs or in hallways. I tend to talk about safely keeping pace with peers over a set distance with/without assist or cues.
Tara

Obesity is a serious medical condition in any age. Our school-based teams usually look our way when a child is overweight, as he/she does present with decreased coordination and endurance, don’t do as well in PE, and has social limitations, etc., and we know more than a thing or two about fitness after all. It is true that we veer slightly away from our traditional approach when we serve an obese child in a school setting.

I agree with the previous comments. Be objective, state facts and recommend accordingly. Use standard tests, scales and charts. You said so yourself that the child is scoring low in motor tests, that is one strong factor to recommend PT. Also use the state’s Core Curriculum for physical development and health, is the child achieving motor benchmarks as well as his/her peers? Interview the family, is the child getting enough physical activity as recommended for his/her age?

So, ethically, assess comprehensively, state your facts objectively and advocate for the child. Whether you continue or discharge, part of your plan of action for an obese child is to train/work with the family and the teachers, connecting them to other providers, such as a nutritionist, or encouraging them to be more active at home as mentioned, or maybe enroll in a physical activity class (swim, dance, soccer)after school, etc.

I agree with the preceding therapists that ultimately it should come down to if the child’s obesity is affecting his or her ability to function independently and safely in school. We cannot be an extra PE class, but many schools do offer adaptive physical education with an emphasis on physical fitness. Sometimes the school nurses will also work with you regarding referrals to outside sources for nutrition, as sadly it is often a FAMILY problem and the entire family would benefit from training.

I also like the idea of consulting with teachers to integrate fitness into the child’s day, and in New York we are under more pressure to minimize pull outs from the educational curriculum.

If it is determined that obesity is the issue, I will tactfully ask them about their BMI and if the pediatrician has had any concerns. Initially asking where they fall on height and weight charts is much easier than them hearing from someone at school, that they think their child is overweight. They most often, not always, have heard it from their doctor. It is a complex family issue that parents need to address, no less difficult than an adult who is not of a healthy weight. There are now often weight management clinics through hospitals that target all aspects for the family. It starts with lifestyle changes at home. Direct PT is not the answer and this issue takes a village!! Quite often this is a family issue.

As others have said here, I will put a student on PT only if there is a school-related deficit which impairs that student’s ability to access the school environment fully. I work in an inner city school district, which carries with it quite a number of barriers to addressing the problem that you mentioned. I had a referral recently of an overweight boy transferring to us from another state, and who has PT on his special ed program. Upon testing, he passed with flying colors and does not need PT in the school. So, when we meet with his mother to go over the results, I will discuss the rules under which school-based PT is provided, will discuss the CDC’s nomogram, offer nutritional information, and a referral to our local hospital’s nutrition services. In addition, we run a pediatric obesity wellness exercise and education program in our outpatient department, that is funded with donations. I’ll offer that as well. On an as-needed basis, I will work with gym teachers and classroom teachers on strategies to keep students active, while paying attention to any chronic conditions. The bottom line is to stick to the rules about who qualifies for school-based PT. I hope this is helpful.

All of the responses are excellent. I want to add that therapists be aware of the risk for diabetes and sleep apnea in overweight children. Approaching the problem of obesity as a medical issue would be appropriate. After discussing the situation/concerns with the child’s parent, a referral to the school nurse and/or pediatrician can be generated or the parent can follow-up for a check-up with a medical professional.

Post from Yvonne:
Hi
In regards to obesity, rather than focus on one child can you try to create a nutrition physical therapy day for the school inviting to your presentation the principal and primary people that govern the school district to assist you with meal changes and send info to the house and or set a gym day to assess each child to win a prize. We need to involve everyone not to make it personal I hope I help Best regards Yvonne

I think this is a pretty basic question as to the eligibility for school-based PT. I ask the same question during every evaluation referral or annual review when determining a student’s initial or continued eligibility: Are my specific skills as a licensed physical therapist going to provide this student with a unique means to which he or she can make meaningful educational progress? In this case of obesity, the answer is clearly “no”. No skills that are unique to me, as a physical therapist, are going to help this child succeed in school. I do have some nutrition training, some fitness knowledge, etc., but so does the school nurse and the physical education teacher. In cases like this, it is clear to me that my skills are not “unique” enough to render this child eligible for school-based PT.